1. Field of the Invention
The present invention relates generally to a system and process for managing health care and addressing many of the problems faced by those involved with health care today; payers, patients, and providers. More particularly, it relates to such a system and process which interfaces with health plan beneficiaries who have decided to seek health care services from a doctor and/or some other type of health care provider. These calls are answered by nurses and/or other types of health care professionals, who use the proprietary information tools and processes of the network management system (NMS) to help patients assess their health needs and then select appropriate care.
2. Description of the Prior Art
Using conventional approaches to access the health care system, many individuals with self-correcting conditions will see a doctor and begin to receive care that in most cases will not have medical benefit Many will also receive treatment from a provider who is not the most qualified to treat their particular condition. For such reasons, there has been an effort to develop alternative approaches.
Consumer Health Services currently operates a telephone-based, hospital and doctor marketing and referral service under the brand name of Prologue. Consumer Health collects information about doctors and makes patient referrals to doctors.
Other approaches have been suggested in the prior art For example, U.S. Pat. No. 4,852,173, issued Jul. 25, 1989 to Bahl et al. discloses the use of branched tree logic, primarily for a speech recognition system. However, the teaching of this patent also suggests application of branched tree logic for medical applications as follows: "While the invention will most often refer to speech recognition and specifically to next word prediction, the described invention is equally applicable to any pattern recognition system in which a next event or next data predictor is based upon a past event or given set of data. For example, given a list of a patient's medical symptoms, what is the best course of treatment or what is the best diagnosis." (Column 1, lines 60-69). However, the system and process there disclosed imposes the limitation that all nodes in the branched tree logic be related to each other in terms of probability or be probabilistically dependent on each other. It is believed that such a limitation is not appropriate for an effective medical network management system and process, because numerical data to establish the dependencies is not available. There is therefore a need for patient screening system and process in which the branched chain logic does not require nodes that are related probabilistically or probabilistically dependent on one another.
U.S. Pat. No. 4,838,275, issued Jun. 13, 1989 to Lee and U.S. Pat. No. 4,290,114, issued Sep. 15, 1981 to Sinay both disclose systems and processes including patient screening by non-physicians, but without the use of branched chain logic for such screening.
A variety of approaches are also known in the art for systems and processes that automate medical diagnosis. For example, U.S. Pat. No. 5,263,123 discloses an expert system using a form of fuzzy logic for medical diagnosis. However, it should be recognized that diagnosis is a different problem than managing access to medical providers who can then make a diagnosis and institute effective treatment.
Accordingly, the art relating to patient screening and provider referral is fairly well developed. However, a need remains for further development of such systems and processes, especially in light of current movement to a universal care medical system.